New Client Registration Form

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.
  • Pet Owner's Name

  • If an alternate number is listed above, please indicate where we will reach you at this number (Work, home, etc)
  • Pet Information

    Pet #1
  • Pet Information

    Pet #2
  • Pet Information

    Pet #3
  • I grant to Ebenezer Animal Hospital, its representatives and employees, the right to take photographs of me and/or my pet, and to use and publish the same in print and/or electronically. I agree that Ebenezer Animal Hospital may use such photographs of my pet and/or me with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, social media, advertising, and Web content.